Healthcare Provider Details

I. General information

NPI: 1649935784
Provider Name (Legal Business Name): MRS. DEBRA ANN WATFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5667 N 57TH ST
MILWAUKEE WI
53218-2416
US

IV. Provider business mailing address

5667 N 57TH ST
MILWAUKEE WI
53218-2416
US

V. Phone/Fax

Practice location:
  • Phone: 414-551-2066
  • Fax: 414-455-8112
Mailing address:
  • Phone: 414-551-2066
  • Fax: 414-455-8112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: